PubMed Health⌕ Search

Biomedical subjects

Jeanne Miranda

Publications and source records attributed to Jeanne Miranda.

15 recordsLinked to original sources
PubMed2003

Treating depression in predominantly low-income young minority women: a randomized controlled trial.

CONTEXT: Impoverished minority women experience a higher burden from depression than do white women because they are less likely to receive appropriate care. Little is known about the effectiveness of guideline-based care for depression with impoverished minority women, most of whom do not seek care. OBJECTIVE: To determine the impact of an intervention to deliver guideline-based care for depression compared with referral to community care with low-income and minority women. DESIGN, SETTING, AND PARTICIPANTS: A randomized controlled trial conducted in the Washington, DC, suburban area from March 1997 through May 2002 of 267 women with current major depression, who attended county-run Women, Infants, and Children food subsidy programs and Title X family planning clinics. Outcomes Hamilton Depression Rating Scale measured monthly from baseline through 6 months; instrumental role functioning (Social Adjustment Scale) and social functioning (Short Form 36-Item Health Survey) measured at baseline and 3 and 6 months. INTERVENTIONS: Participants were randomly assigned to an antidepressant medication intervention (trial of paroxetine switched to buproprion, if lack of response) (n = 88), a psychotherapy intervention (8 weeks of manual-guided cognitive behavior therapy) (n = 90), or referral to community mental health services (n = 89). RESULTS: Both the medication intervention (P<.001) and the psychotherapy intervention (P =.006) reduced depressive symptoms more than the community referral did. The medication intervention also resulted in improved instrumental role (P =.006) and social (P =.001) functioning. The psychotherapy intervention resulted in improved social functioning (P =.02). Women randomly assigned to receive medications were twice as likely (odds ratio, 2.04; 95% confidence interval, 0.98-4.27; P =.057) to achieve a Hamilton Depression Rating Scale score of 7 or less by month 6 as were those referred to community care. CONCLUSIONS: Guideline-concordant care for major depression is effective for these ethnically diverse and impoverished patients. More women engaged in a sufficient duration of treatment with medications compared with psychotherapy, and outcome gains were more extensive and robust for medications.

Adult↗
PubMed2003

Impact of a primary care quality improvement intervention on use of psychotherapy for depression.

We examine the impact of the two Partners in Care (PIC) primary care quality improvement (QI) interventions on counseling services. The QI interventions aimed to increase service use, and thereby improve outcomes, and have been shown to indeed improve patient outcomes (e.g., K. B. Wells et al., 2000). But whether or not use of counseling services actually increased has not yet been examined. The QI interventions contained many overlapping elements; however, QI-Therapy emphasized cognitive-behavioral therapy, and QI-Meds emphasized medications and case management. QI-Therapy patients used more counseling than UC patients at 6 months, though increases were modest. Some treatment effects persisted until 12 months, but not beyond. QI-Therapy and QI-Meds patients reported more treatment overall (therapy or medication) than UC patients at 6 months, and this effect persisted in the QI-Meds clinics until 12 months. Treatment effects were more pronounced among those most in need. Despite high rates of referral to psychotherapy within the QI-Therapy clinics (81%), only a minority of patients actually attended a psychotherapy session within the study (30%). We discuss the uptake of therapy in this study as a way to inform future efforts at QI.

Adult↗
PubMed2003

Improving care for minorities: can quality improvement interventions improve care and outcomes for depressed minorities? Results of a randomized, controlled trial.

OBJECTIVE: Ethnic minority patients often receive poorer quality care and have worse outcomes than white patients, yet practice-based approaches to reduce such disparities have not been identified. We determined whether practice-initiated quality improvement (QI) interventions for depressed primary care patients improve care across ethnic groups and reduce outcome disparities. STUDY SETTING: The sample consists of 46 primary care practices in 6 U.S. managed care organizations; 181 clinicians; 398 Latinos, 93 African Americans, and 778 white patients with probable depressive disorder. STUDY DEIGN: Matched practices were randomized to usual care or one of two QI programs that trained local experts to educate clinicians; nurses to educate, assess, and follow-up with patients; and psychotherapists to conduct Cognitive Behavioral Therapy. Patients and physicians selected treatments. Interventions featured modest accommodations for minority patients (e.g., translations, cultural training for clinicians). DATA EXTRACTION METHODS: Multilevel logistic regression analyses assessed intervention effects within and among ethnic groups. PRINCIPAL FINDINGS: At baseline, all ethnic groups Latino, African American, white) had low to moderate rates of appropriate care and the interventions significantly improved appropriate care at six months (by 8-20 percentage points) within each ethnic group, with no significant difference in response by ethnic group. The interventions significantly decreased the likelihood that Latinos and African Americans would report probable depression at months 6 and 12; the white intervention sample did not differ from controls in reported probable depression at either follow-up. While the intervention significantly improved the rate of employment for whites and not for minorities, precision was low for comparing intervention response on this outcome. It is important to note that minorities remained less likely to have appropriate care and more likely to be depressed than white patients. CONCLUSIONS: Implementation of quality improvement interventions that have modest accommodations for minority patients can improve quality of care for whites and underserved minorities alike, while minorities may be especially likely to benefit clinically. Further research needs to clarify whether employment benefits are limited to whites and if so, whether this represents a difference in opportunities. Quality improvement programs appear to improve quality of care without increasing disparities, and may offer an approach to reduce health disparities.

Black or African American↗
PubMed2003

Treatment of depression among impoverished primary care patients from ethnic minority groups.

OBJECTIVE: The aim of this study was to determine whether supplementing traditional cognitive-behavioral therapy for depression with clinical case management would reduce the rate of dropout from care and improve outcomes for ethnically diverse, impoverished medical outpatients. METHODS: The study was a randomized trial that compared cognitive-behavioral group psychotherapy alone (N=103) with the same therapy supplemented by clinical case management (N=96). RESULTS: The patients who received supplemental case management had lower dropout rates than those who received cognitive-behavioral group therapy alone. Supplemental case management was associated with greater improvement in symptoms and functioning than cognitive-behavioral therapy alone for patients whose first language was Spanish (N=77) but was less effective for those whose first language was English (N=122). CONCLUSIONS: Supplemental case management improves retention in traditional mental health outpatient care and can improve outcomes for Spanish-speaking patients.

Adult↗
PubMed2003

Primary care attributes and care for depression among low-income African American women.

OBJECTIVES: We examined the association between attributes of primary care providers and care for depression, from a patients' perspective, among a sample of predominantly low-income African American women. METHODS: Computer-assisted telephone interviews were conducted among a population-based sample of 1202 women residing in Washington, DC. RESULTS: Respondents whose primary care physicians provided more comprehensive medical services were more likely to be asked about and treated for depressive symptoms than women whose providers were less medically comprehensive. Women who rated their providers as having more respect for them also were more likely to be asked about and treated for depression. CONCLUSIONS: More comprehensive primary care delivery and a physician-patient relationship focused on mutual respect are associated with greater rates of physician inquiry about and treatment for depression among vulnerable women.

Adult↗
PubMed2002

Overcoming barriers to reducing the burden of affective disorders.

Affective disorders impose a substantial individual and societal burden. Despite availability of efficacious treatments and practice guidelines, unmet need remains high. To reduce unmet need and the burden of affective disorders, information is needed on the distribution of burden across stakeholders, on barriers to reducing burden, and on interventions that effectively reduce burden at the levels of practice, community, and policy. This article provides the report of the Working Group on Overcoming Barriers to Reducing the Burden of Affective Disorders, for the National Institute of Mental Health Strategic Plan on Mood Disorders. We review the literature, identify key gaps, and recommend new research to guide national efforts to reduce the burden of affective disorders.

Community Health Services↗
PubMed2002

Barriers to reducing burden of affective disorders.

This paper summarizes 3 sets of barriers to reducing burden of affective disorders including factors that contribute to 1) the risk, course, and outcomes of affective disorders; 2) help-seeking and use of health and mental health services for affective and other mental disorders; and 3) the appropriateness of treatments used for affective disorders. On the basis of this review, the authors recommend research needed to identify modifiable barriers to reducing the burden of affective disorders and to identifying opportunities to reduce these barriers. This new research should focus on clarifying societal, family, and consumer, clinician, and system barriers to recognizing disorders, seeking and providing care, and adhering with guideline concordant care, and should include barriers that apply to both treatment and prevention services.

Comorbidity↗
PubMed2002

Community-based interventions.

This paper explores the potential of community-based, public health-oriented interventions as a tool for reducing the burden of affective disorders on individuals, their families, and communities. The paper reviews the use of community-based interventions with other health-related problems and describes potential applicability for affective disorders such as changing public attitudes, reducing social stigma, facilitating access, or supporting treatment adherence for populations in their community settings. An agenda for developing this field of intervention research is proposed.

Community Mental Health Services↗
PubMed2002

Research on reducing burden of affective disorders for special populations: introduction and general recommendation.

Populations should be prioritzed for research on reducing the burden of affective disorders based on expected or known burden or current level of unmet need for care. We recommend a focus on ethnic minorities, impoverished women, children, adolescents, and individuals with bipolar illness. Studying effectiveness of interventions and the efficiency of delivery systems are priorities for special popultions.

Adolescent↗
PubMed2002

Ethnic minorities.

Ethnic minorities have relatively similar rates of mood disorders as do white Americans, but they are much less likely to receive appropriate care. Barriers to care include lack of insurance, few minority providers' racism, and distrust of care providers. A priority in research is identifying practice interventions and policies that could eliminate disparities in care.

Cost of Illness↗
PubMed2002

Research development mechanisms.

Studies designed to reduce the burden of affective disorders should apply and develop theories and methods from diverse social sciences that could strengthen current interventions. A series of papers from diverse fields, such as quality engineering, behavioral economics, etc. might be a needed first step. Methodological research on design strategies such as group-level randomized trials, or instrumental variables analyses are needed. Finaly, qualitative studies to understand diverse stakeholder views are also needed. To pursue these areas, interdisciplinary training programs are needed to develop skilled researchers to study communities and community-based delivery settings. New research infrastructures are needed to support community and research collaborations, as well as supporting development of new technologies to enable diffusion of care.

Cost of Illness↗
PubMed2002

Burden of illness.

The burden of affective disorders includes costs and the pain and suffering of affected individuls. Burden can be perceived from social and private perspectives. Although no ideal measure of burden exists, ample evidence documents the extensive cost and other negative impacts of affective disorders. Affective disorders are associated with disruptive family relations, higher health care costs for comorbid conditions, elevated rates of suicide, and lower productivity. Reserch should focus on improving measures of burden in general and on quantifying burden from the standpoint of diverse population groups.

Cost of Illness↗
PubMed2002

Gender issues and socially disadvantaged women.

Gender differences in overcoming barriers to mental health care for affective disorders have not been studied. Further, the role of mental health care for parents as it affects child outcomes is important but currently not well studied. In particular, care for disadvantaged young women is an area in need of further research.

Cost of Illness↗
PubMed1999

The need for mental health services research focusing on poor young women.

Despite the fact that the relationship between poverty and increased risk for a broad spectrum of mental disorders has been documented for several decades, very little is known about providing mental health treatments to poor individuals. In this paper, we emphasize the importance of developing, and empirically evaluating, sensitive and appropriate interventions for poor young women who suffer from common mental disorders. WHO ARE THE US POOR?: In the US, nearly 14% of individuals live in poverty, and another 20% in near poverty. The poor are disproportionally women and children such that 63% of female-headed households are poor. Young women and ethnic minorities are over-represented among the poor also, with 55% of those living below the poverty level being minorities. NEEDS AND BARRIERS TO CARE AMONG POOR, YOUNG WOMEN: The poor have more mental disorders than those with more resources. Further, women are twice as likely as men to have a mood or anxiety disorder, including major depression and post-traumatic stress disorder (PTSD), with younger women at higher risk than older women. Research alos indicates that poor women have high exposure to traumatic events and cumulative adversity that is directly related to their mental health. This history may serve, in part, as a barrier to seeking mental health care. Other barriers in this population include lack of insurance, lack of access to primary care where mental disorders might be detected, practical problems like lack of childcare or transportation, and the inflexibility of low-income service jobs. Religious beliefs and attitudes about mental health treatment may play a role as well. Recent policy changes in the US have contributed to the vulnerability of this group as eligibility for welfare programs has reduced, and time limits have decreasd. Services for immigrants are also severely limited, and managed care strategies for those in the public sector may be confusing. IMPORTANT, UNANSWERED QUESTION: More needs to be learned about the mental health status and needs of poor women, along with the impact of loss of public support on their physical and mental health. Access to mental health care within a managed care setting also needs to be addressed, and care taken to understand the particular needs of poor populations that will actually make these services accessible to them. Insufficient attention has thus far been paid to the cost implications of providing these services to the poor. While providing treatment is associated with significant costs, the costs of not providing care, especially the effects of depression on offspring, should not be overlooked. CHALLENGES TO EXAMINING MENTAL HEALTH IN POOR WOMEN: A number of suggestions were made for addressing practical and methodological challenges to providing mental health services. These include placing services for these individuals within their familiar medical settings, which requires close working relationships between psychiatric and medical personnel within these settings. Outreach is a necessary part of getting poor women into treatment, and should be a routine part of helping women become engaged with caregivers. Providing culturally sensitive treatments is an important focus too, through developing knowledge about the culturally based customs and expectations of target groups. Measurement issues need to be attended to, as most research instruments have been developed on middle class populations, and have not been examined for their psychometric properties and norms in less advantaged groups. Careful translation techniques are also required. Finally, working with institutions sponsoring research to educate them about special problems and challenges with these groups will help improve the quality and efficiency of the work accomplished.

Journal Article↗